Abstract

AIMS AND METHOD

To describe the effect of a postal reminder system on UK adult psychiatry
clinic attendance. A literature review was completed and a serial
cross-sectional survey of patient attendance records in an inner-city
psychiatric hospital during 2006 and 2007 was undertaken.

RESULTS

A simple postal prompt reduces non-attendance by up to 50% and data from
the serial cross-sectional survey of attendance records (n=36)
powered at 77% supported this finding. Postal prompts in the survey accounted
for 30% improvement in the variance (r2).

CLINICAL IMPLICATIONS

A simple postal prompt that takes less than 30 s to read, sent up to 2
weeks prior to the appointment improves attendance by up to 50% and is useful
for maintaining standards of excellence.

Missed appointments continue to be a major contributor to wasted resources
in planned mental healthcare services and non-attendance is an area of concern
for all healthcare providers. The national figure of 12% for non-attendance at
out-patient clinics in the UK hides large variations between specialties and
between regions. Studies report figures that range from 5% to 34%
(Sharp & Hamilton, 2001). A
Cochrane review (Reda & Makhoul,
2001) suggests that a very simple prompt to attend clinic is
financially sound advice for managers as well as being good clinical
practice.

Method

Literature search

A literature review of peer-reviewed psychiatry journals 1974–2007
was conducted. A number of databases were searched (EMBASE, MEDLINE, PsycLit,
King’s Fund, CINAHL, PsycINFO) with keywords: ‘psychiatry
out-patient’, ‘improve out-patient attendance’, ‘
non-attendance’. The search was limited to papers published in
English and peer-reviewed journals. Among the publications found, seven were
suitable for inclusion (Rusius,
1995; Killaspy et al,
2000; Reda & Makhoul,
2001; Sharp & Hamilton,
2001; Hamilton et al,
2002; McIvor & Ek,
2004; Hawker, 2007)
and the decision to include a study was based on whether it was carried out on
an adult service in the UK and whether it was informative on improving
out-patient attendance. The papers under review are presented in
Table 1 (Sharpe & Hamilton,
2001 is not included as it is not a research study).

Serial cross-sectional survey

Individuals (n=36) attending an out-patient clinic in an
inner-London psychiatric hospital were monitored for attendance over a
12-month period from 2006 to 2007. Individuals had been randomly allocated to
the specialist registrar clinic by accrual over time. Other parallel clinics
run by consultant and senior house officer were similarly allocated. After the
first 6 months of monitoring, all those due to attend were sent a simple
orientation statement taking less than 30 s to read 2 weeks prior to their
appointment. Attendance was analysed by converting the raw data into
continuous variables thereby making them comparable. Paired t-testing
with P<0.05 was carried out on mean differences in attendance
ratios. Five people were not included in the study (one suicide, two
discharged before the end of the study and two failed to respond to repeated
invitations to attend). A scatterplot of appointments offered v.
appointments attended was constructed and a straight line was drawn by the
method of linear regression (Swinscow,
1997) with y = rx+c. A correlation
coefficient of r>0.8 is generally described as strong correlation.
The coefficient of determination (r2) (variance)
represents the percentage of data that is closest to the line of best fit,
accounting for the linear relationship. The amount of variation remaining
unexplained is therefore 1 — r2.

Results

Postal reminders

A randomised controlled study (Rusius,
1995) has shown that a postal reminder sent 3 days prior to the
appointment reduced non-attendance by at least 50% (P<0.05). It
was suggested that the non-attending group were mixed in terms of
socio-demographic factors, diagnosis and severity of symptoms. Other forms of
postal reminder systems have included an opt-in system
(Hawker, 2007). Opt-in systems
require the patient to respond in some way to the offer of an appointment.
Evidence from nine studies, including one controlled trial, suggested that
median non-attendance rates fell from around 27% to around 4% when opt-in
systems were introduced. An important question concerns the risk to those who
fail to opt-in and are therefore not seen.

Consistent factors that distinguish non-attenders

Waiting times

One factor often quoted is length of waiting time and forgetting first
appointments (Rusius, 1995;
Sharp & Hamilton, 2001).
However, no data reached significance (P>0.05) when non-attending
new patients were compared with non-attending follow-up patients.

Severity of illness

A prospective cohort design (Killaspy
et al, 2000) was used to show differences between new and
follow-up patients and that primary diagnosis in new patients was mostly
depression (P<0.001) and in follow-up patients was mostly
schizophrenia (P=0.003). Follow-up patients were more severely ill
than new patients and follow-up non-attenders were more severely ill than
follow-up attenders. Non-attending for 12 or more months made admission
significantly more likely in follow-up patients (P=0.018).

Deprivation

Doctors training

Non-attendance rates were examined
(McIvor & Ek, 2004) by
cross-sectional survey of patients seen by psychiatrists of different grades
and a consultant clinical psychologist over a 21-month period. The clinical
psychologist’s patients had the lowest rate of non-attendance (7.8%),
followed in turn by those of consultant psychiatrists (18.6%), specialist
registrars (34%) and senior house officers (37.5%). Factors such as continuity
of care, perceived clinical competence and the provision of non-medical
interventions might have an impact on attendance rates.

Serial cross-sectional survey

Attendance records of 31 patients were analysed. There were 14 females
(45%) and 17 males (55%). The average age was 42.6 years with average male age
43.5 years and female age 39.9 years. After 6 months of monitoring, two-thirds
(66%) of appointments had been attended. For the second 6 months, reminders
were sent and attendance was 75%.

Attendance was computed as the ratio of appointments attended to
appointments offered. This was done for each 6-month block and mean attendance
was compared: 0.57:0.71=1.25. The paired Student’s t-test was
used to compare means, and at P<0.05, critical
t(30);0.05=1.697. The mean difference in attendance was 0.354
(s.d.=0.285; 95% CI 0.45–0.25); t=mean difference/s.d.; √
n=7; and H0 is rejected as no significant
differences between groups. This confirmed that the ratio of 1.25 attendance
after sending a reminder was not due to chance alone.

Discussion

Poor psychiatric out-patient attendance continues to be an extravagant
waste of resources with wasted appointments being up to 35% or higher. It has
been suggested that non-attending patients differ from those who attend. This
might have something to do with patient’s perceptions of the treatment.
New patients who do not attend are usually depressed and less unwell than
follow-up patients. It is often quoted that waiting time and forgetfulness
contribute to non-attendance. However, the ratio of attended:offered is
probably more complex, the main associations being male, youth, substance
misuse and levels of socio-economic deprivation as measured by the Jarman
Index. It is possible that doctors of lesser seniority have higher
non-attendance rates.

It remains unclear when best to send reminders; prompts sent at 14 days
seem to work as well as prompts 3 days prior to the appointment. The effect of
a prompt accounts for r2=56% (P<0.001) of the
variance where y=3/4x+0 as opposed to
y=1/2x+0 prior to the prompt. The rest of the variance being
unaccounted for and due to lurking variables such as outliers, levels of
socioeconomic deprivation, transport, weather, child care or
doctor–patient relationship, which could all theoretically influence
attendance. By comparing r2 for each 6-month period, there
was a 30% improvement which implies that the influence of confounders was
reduced by sending a prompt and that there was a strong correlation
(r=0.75) between prompts and improved attendance.

Conclusion

Sending postal reminders prior to the appointment helps to maintain good
clinical practice and is in concordance with clinical governance. It also
helps to maintain standards of excellence. The reliability of the study would
be improved if larger out-patient numbers were used and comparisons made with
other out-patient settings in adult psychiatry or comparisons with consultant
or senior house officer clinics.

Correlation does not prove causation and therefore the relationship between
reminders and attendance must be a complex one worthy of further study because
of the significant effect of confounders and the unknown meaning that the
patient attaches to the prompt and the uncertainty about when best to send a
reminder.